CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 52, Number 2, 256–269

r 2009, Lippincott Williams & Wilkins

The Partograph for

the Prevention of
Obstructed Labor
MATTHEWS MATHAI, MD, MObstet, PhD
Department of Making Pregnancy Safer, World Health
Organization, Geneva, Switzerland

Abstract: Obstructed labor is an important cause of progress in labor early, and to initiate
maternal and perinatal mortality and morbidity. The appropriate interventions to prevent pro-
partograph graphically represents key events in labor
and provides an early warning system. The World longed and obstructed labor.1,2
Health Organization partographs are the best known
partographs in low resource settings. Experiences with
World Health Organization and other types of parto-
graphs in low resource settings suggest that when used Global Burden of Obstructed
with defined management protocols, this inexpensive
tool can effectively monitor labor and prevent ob- Labor
structed labor. However, challenges to implementa- Obstructed labor occurs when there is a
tion exist and these should be addressed urgently. significant disproportion between the di-
Key words: partograph, obstructed labour, maternal mensions of the fetal presentation and the
mortality, maternal morbidity, perinatal mortality, mother’s pelvis during labor. Information
perinatal morbidity, low resource settings, World
Health Organization on the incidence of and mortality from
prolonged and obstructed labor is incom-
plete and patchy. The reported incidence
The partograph (or partogram) is a tool of obstructed labor varies widely: from as
that graphically represents key events low as 1% in some populations to up to
during labor. This tool is recommended 20% in others.3 About 42000 deaths or
for routine monitoring of labor to provide 8% of all maternal deaths in 2000 were
an early warning system. The partograph estimated to be due to obstructed labor.3
helps the care provider to identify slow Often, there is paucity of vital registration
data in settings where obstructed labor
and maternal deaths are common.4 More-
Correspondence: Matthews Mathai, MD, MObstet,
PhD, Department of Making Pregnancy Safer, World over, when a woman dies as a result of
Health Organization, Avenue Appia 20, Geneva, obstructed labor, the death may not be so
Switzerland CH 1211. E-mail: mathaim@who.int classified under the final cause of death.
Disclaimer: The author is a staff member of the World Death may be reported as caused by
Health Organization. However this manuscript does not
necessarily represent the decisions or the stated policy of sepsis, ruptured uterus or hemorrhage
the World Health Organization. rather than owing to the underlying cause,

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 52 / NUMBER 2 / JUNE 2009

256 | www.clinicalobgyn.com
 Partograph for the Prevention of Obstructed Labor 257

which may be cephalopelvic disproportion imaging techniques to identify women at

or abnormal presentation. Use of proxy high risk of obstructed labor are described
markers, like cesarean delivery rates or in text books.8,9 The x-ray pelvimetry has
instrumental delivery rates, are no longer been found insufficiently predictive of
valid given the wide variations in these fetopelvic disproportion to justify obste-
rates resulting from varying practices.5,6 tric intervention and is associated with
Obstructed labor is an important cause more cesarean sections and no improve-
of maternal morbidity. Obstetric fistula is ment in perinatal outcomes.10 Neither
a devastating yet often neglected injury clinical nor ultrasound estimation of fetal
that occurs as a result of prolonged or weight have been shown to be effective in
obstructed labor. Without surgical repair, predicting obstructed labor.7
the physical consequences of fistula are All these methods have poor predictive
severe-urinary and/or fecal incontinence, values, as the changes that occur in the
fetid odor, frequent pelvic and/or urinary dimensions of the fetal head and the
infection, pain, infertility, and often-early maternal pelvis during labor cannot be
mortality. The social consequences of fis- successfully predicted by any of these
tula are immense: these women are often screening methods. Labor is perhaps the
ostracized from society, abandoned by best test for the diagnosis of dispropor-
husbands, families, and communities, tion. During labor, a decrease in the
destitute, and poor.3 An estimated presenting dimensions of the fetal head
2,951,000 disability adjusted life years brought about by increasing flexion,
were lost in 2000 owing to obstructed asynclitism and molding, and the increase
labor.3 in maternal pelvic dimensions through
Prolonged and obstructed labor is also relaxation of pelvic joints (‘‘give of the
associated with fetal hypoxia, birth trau- pelvis’’) help to overcome many cases of
ma, and infection resulting in intrapartum cephalopelvic disproportion suspected
or early newborn deaths and perinatal before onset of labor.
morbidity. Therefore, prevention of Assessment of progress in labor should
obstructed labor is an important interven- therefore identify those women who are
tion towards reducing maternal and peri- less likely to deliver normally. Early diag-
natal mortality and morbidity, and in nosis of slow progress and appropriate
achieving the Millennium Development interventions should therefore help in
Goals 4 and 5. preventing obstructed labor. The parto-
graph (or partogram) is a simple tool that
has been used for this purpose.
Approaches for the Prediction
of Obstructed Labor Historical Background
Attempts have been made in the past to Friedman was the first obstetrician to
identify women at risk for obstructed describe the progress of labor graphi-
labor. Short stature and small shoe size cally.11 He reported the change in cervical
have been used as indirect markers of a dilatation occurring in labor. The
small pelvis and potential cephalopelvic progress was recorded in centimeters of
disproportion and thus as markers of risk dilatation per hour. The resulting graph
of obstructed labor.7 The predictive va- was an S-shaped curve.
lues of these criteria are too low to justify Philpott subsequently used this infor-
direct obstetric indication.7 mation to develop a tool initially referred
External and internal pelvimetry, to as cervicograph.12–14 He used this tool
either by clinical measurements or by in Zimbabwe (then Rhodesia) in an

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258 Mathai

attempt to use the service of midwives Hendricks et al15 proposed designating

efficiently in the health services where time of arrival at hospital rather than
doctors were in short supply. From this reported time of onset of labor as 0 time
original cervicograph, Philpott developed and this concept has been included in the
a partograph, a practical tool for commonly used partographs. No differ-
recording all intrapartum details, not just ences in progress of cervical dilatation
cervical dilatation. rates have been observed among the
Philpott subsequently added an ‘‘alert different racial groups studied16; there-
line’’. This was a straight line, not fore the basic concepts of the partograph
curved like Friedman’s cervicographs, are universally applicable.
and was a modification of the mean rate
of cervical dilatation of the slowest 10%
of primigravid women in the active phase
of labor. The alert line represented a pro- Types of Partographs
gress rate of 1 cm per hour. The purpose Various types of partographs have been
of the alert line was ‘‘to aid the midwife in described. Preprinted paper versions of
a peripheral unity., or a general practi- the partograph are available. In the ab-
tioner, midwife, or house surgeon in any sence of preprinted partographs, users
hospital to detect at the earliest possible have manually drawn key features of the
moment the abnormal labor’’.14 Should a cervicograph on blank paper and have
woman’s cervical dilatation progress successfully plotted progress of labor.
more slowly than 1 cm per hour, it would Stencils with different cervical dilata-
cross this alert line and arrangements tion-time curves, constructed with refer-
made to transfer her from a peripheral ence to cervical dilatation on admission to
unit to a central unit where slow progress the labor ward,16 as well as circular parto-
in labor could be managed. graphs17 and an electronic partograph
The next stage in the development of (www.epartograph.eu) (P Gastaldi, perso-
the partograph was the introduction of an nal communication) have been used for
‘‘action line’’, 4 hours to the right of the labor monitoring.
alert line. This allowed ‘‘time to transfer The way a partograph is presented may
the patient without impairing the success affect the user’s perception of labor
of the essential active management’’,14 progress and thus influence the decision
and also allowed ‘‘many normal patients making.18–21 Interventions are more
to deliver vaginally without active inter- likely if the slope of the labor progress
vention’’.14 Appropriate action could curve seems flat18,19 and if the latent phase
include correction of primary inefficient is included.18
uterine activity with an intervention The alert and action lines must also
such as amniotomy and/or oxytocin satisfy 2 criteria: must be simple to use;
infusion. must separate efficiently the majority of
Although the alert and action lines were normal patients from the abnormal
originally designed for primigravidas, patients in sufficient time to transfer the
Philpott also used them in the manage- latter safely to the central unit for treat-
ment of the multigravidas, who normally ment. The position of the action line has
progress more quickly than primigravi- an impact on cesarean section, interven-
das. However as he noted, ‘‘The difference tion, and maternal satisfaction. When
in application occurs at the time of cross- compared with the 4-hour action line,
ing the action line, for the use of oxytocic the 2 hours action line increases the need
augmentation can be hazardous in the for intervention without improving
multigravid patient’’.14 maternal and neonatal outcomes.20–22

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 Partograph for the Prevention of Obstructed Labor 259

Partograph
Name Gravida Para Hospital number
Date of admission Time of admission Ruptured membranes Hours
200
190
180
170
160
Fetal 150
140
heart rate 130
120
110
100
90
80
Amniotic fluid
Moulding
10
active phase
9

7 t n
Cervix (cm) er tio
[plot X] 6 Al Ac
5

Descent 4

of the head 3
[plot O] 2 latent phase
1

0
Hours
Time

5
4
Contractions 3
per 10 min
2
1

Oxytocin U/L
drops/min

Drugs given
and IV fluids

180
170
160
Pulse 150
140
130
and 120
110
BP 100
90
80
70
60

Temp°C
protien
Urine acetone
volume

FIGURE 1. The ‘‘composite’’ World Health Organization partograph.23

WORLD HEALTH ORGANIZATION in most low resource countries and are

PARTOGRAPHS therefore described in more detail. Since
The World Health Organization (WHO) the 1990’s, WHO has published 3 differ-
partographs are probably the best known ent types of the partograph.

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260 Mathai

 The first of these partographs23 (the com- similar for nulliparas and multiparas when
posite partograph) includes a latent phase monitored with the modified WHO
of 8 hours and an active phase starting at partograph.27
3 cm cervical dilatation (Fig. 1). The alert  Further modification was made to develop
line with a slope of 1 cm per hour com- the third WHO partograph for use by
mences at 3 cm dilatation; the action line is skilled attendants in health centers.1
4 hours to the right of the alert line and This simplified partograph is color coded
parallel to it. This composite partograph (Fig. 3). The area to the left of the alert
also provides space for recording descent of line in the cervicograph is colored green,
the fetal head, indicators of maternal and representing normal progress. The area
fetal well-being and medications adminis- to the right of the action line is colored
tered. Cervical dilatation is recorded on the red, indicating dangerously slow progress
partograph at each vaginal examination in labor. The area in between the alert
(usually once in 4 h). If the cervix is less and action line is colored amber, indicating
than 3 cm dilated, the first recording of the need for greater vigilance. Cervical
cervical dilatation (on the y-axis) is at 0 dilatation but not descent of the head
hour. If the cervix has dilated to 3 cm or is recorded on this graph, which is
more at the next examination, the next part of a labor record. Other indicators
recording of cervical dilatation is made on of maternal and fetal well-being are
the corresponding point on the alert line. recorded elsewhere in the labor record.
The 2 points are then joined by a broken The composite WHO partograph and
line to indicate transfer from latent phase to the simplified WHO partograph were
active phase. This partograph was used compared in a cross over trial28 in Vellore,
successfully in an international study of India. The composite partograph was
over 35000 women in South East Asia23 rated as less user-friendly than the
(see details below). simplified partograph. Although most ma-
 The modified WHO partograph for use in ternal and perinatal outcomes were similar,
hospitals was published in 2000.2 The latent labor values crossed action line signifi-
phase was excluded in this partograph cantly more often when the composite
(Fig. 2). The active phase commences at partograph was used and women were
4 cm dilatation. The other features are the more likely to undergo cesarean delivery.
same as the composite WHO partograph. The simplified partograph was more likely
The reason for excluding the latent phase to be completed.
were that interventions are more likely if
the latent phase is included and because
staff reported difficulties in transferring SOME OTHER PARTOGRAPHS
from latent to active phase.18,24,25 The  A simplified round partogram was com-
choice of 4 cm was made to reduce the risk pared with the composite WHO parto-
of interventions in multiparous women graph in Seno province, Burkina Faso.17
with patulous cervices (less than 4 cm) The 2 most common errors in the
who were not yet in labor. A study of the utilization of the composite WHO parto-
modified WHO partograph in Wolisso graph-incorrect recording at the initial
Town, Ethiopia26 concluded that labor examination and at the transition from
could be managed without the latent phase latent to active phase were largely avoided
being plotted on a partograph. However, a with use of the round partogram. However
labor management protocol for the latent this partograph is not widely used.
phase should be instituted with clear  A second-stage partogram has been de-
guidelines on the frequency of observa- scribed.29 This is on the basis of descent
tions, as women with less than 4 cm cervical and position of the fetal head. Normo-
dilatation on first examination in labor are grams have been developed for nulliparous
more likely to experience complicated and multiparous women. The best scores
deliveries. A study in Nigeria reported are associated with occipito-anterior pre-
that labor progress and duration were sentation and stations below + 1 cm.

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 Partograph for the Prevention of Obstructed Labor 261

The WHO Partograph

Name Gravida Para Hospital number
Date of admission Time of admission Ruptured membranes Hours
200
190
180
170
160
150
Fetal 140
heart rate 130
120
110
100
90
80
Amniotic fluid
Moulding
10

8
t
er
Cervix (cm)
7 Al tio
n
[plot X] Ac
6

4
Descent
3
of the head
[plot O] 2

0
Hours
Time

Contractions 3
per 10 min
2

Oxytocin U/L
drops/min

Drugs given
and IV fluids

180
170
160
Pulse 150
140
130
and 120
110
BP 100
90
80
70
60

Temp°C

protien
Urine acetone
volume

FIGURE 2. The ‘‘modified’’ World Health Organization partograph.2

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262 Mathai

PARTOGRAPH
USE THIS FORM FOR 10 cm
MONITORING ACTIVE

CERVICALDILATATION
LABOUR 9 cm

8 cm

7 cm

6 cm

5 cm

4 cm

Sample form to be adapted. Revised on 13 June 2003.

FINDINGS TIME
Hours in active labour 1 2 3 4 5 6 7 8 9 10 11 12
Hours since ruptured membranes
Rapid assessment B3-B7
Vaginal bleeding (0 + ++)
RECORDS AND FORMS

Amniotic fluid (meconium stained)

Contractions in 10 minutes
Fetal heart rate (beats/minute)
Urine voided
T(axillary)
Pulse (beats/minute)
Blood pressure (systolic/diastolic)
Cervical dilatation (cm)
Delivery of placenta (time)
Oxytocin (time/given)
Problem-note onset/describe below

Partograph N5

FIGURE 3. The ‘‘simplified’’ World Health Organization partograph.1

Increasing total scores at the start of the took place in hospital settings. It was not
second-stage of labor were associated with until over 2 decades after Philpott’s
increasing chance of spontaneous vaginal reports12,13 that a very large field trial
delivery (odds ratio (OR) 1.68 for nulli- of the partograph was conducted by the
paras and 1.59 for multiparas), decreasing
WHO to establish its effectiveness.23 The
chance of instrumental vaginal delivery
(OR 0.67 for nulliparas and 0.64 for multi-
partograph used was the composite
paras), and emergency cesarean delivery partograph (described earlier) based on
(OR 0.39 for nulliparas). the principles of Philpott’s partograph.
 An electronic partograph (www.eparto In this prospective multicenter study,
graph.eu) is currently being evaluated the composite WHO partograph was tested
(P Gastaldi, personal communication). in 35,484 women in South East Asia. The
study was conducted using an agreed
Experiences With the management protocol on actions to be
taken on the basis of partograph findings.
Partograph This composite intervention reduced pro-
Before any rigorous evaluation,20 the longed labor from 6.4% to 3.4% and the
availability of the partograph was consid- proportion of augmented labor from 20.7%
ered an important advance in modern to 9.1%. Emergency cesarean births de-
obstetrics that was applicable in all set- creased from 9.9% to 8.3% and intra-
tings. There were several reports of its partum stillbirths from 0.5% to 0.3%.
usefulness from low and high resource Among singleton low risk pregnancies,
settings.30–40 The majority of early studies cesarean births fell from 6.2% to 4.5%.

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 Partograph for the Prevention of Obstructed Labor 263

The use of this partograph in breech pre- require expensive technology, which may
sentations reduced prolonged labor and malfunction.
cesarean births (among multiparas), and A picture is worth a thousand words.
improved perinatal outcomes.41 A partograph review (if well recorded)
Another study aimed to assess the provides rapid, comprehensive informa-
effectiveness of promoting use of the tion about progress in labor when
modified WHO partograph2 by midwives compared with a review of detailed hand
conducting childbirth in maternity homes written case notes.
in Medan, Indonesia.42 This cluster ran- Midwives find the partograph to have
domized trial included 20 midwives who practical benefits in terms of ease of use,
regularly conducted births. Midwives in time resourcefulness, continuity of care
the intervention group were trained in the and educational assistance,45 and these
use of the partograph and advised to use it positive aspects may contribute to im-
while providing care in labor. There were proving maternal and fetal outcomes. In
304 parturient women in the intervention contrast, it has also been reported that the
group and 322 in the control group. Re- partograph’s status within some obstetric
ferral rate in the partograph group units is such that they may restrict clinical
increased (adjusted OR 4.2; 95% confi- practice, reduce midwife autonomy and
dence interval (CI) 2.1-8.7) and there were limit the flexibility to treat each woman as
decreases in vaginal examinations perfor- an individual, factors that could also
med (adjusted OR 0.24; 95% CI 0.12-0.48), impact on clinical and psychologic out-
augmented (adjusted OR 0.21; 95% CI comes. Routine use of the partograph
0.12-0.36) and obstructed labor (adjusted tends to assume that all women will
OR 0.38; 95% CI 0.15-0.96). There were progress in labor at the same rate, and
fewer cesarean births and neonatal resus- this could increase interventions such as
citation in the partograph group but the amniotomy and oxytocin augmentation,
differences were not statistically significant. and use of analgesia resulting in a more
A study in Tanzania43 on the use of the negative labor experience.
partograph in 3 hospitals reported signi- Some have questioned the effectiveness
ficantly lower Apgar scores and poorer of partographs, particularly when used in
maternal outcomes among women who high-income countries.46,47 Also, given
had poor quality partograph-based moni- that partographs were introduced to assist
toring. Five of the 7 perinatal deaths in in rural settings with limited medical input
this study occurred among women with and/or resources, the transferability of
poor partograph-based monitoring. There such a tool to high resource settings may
was a slight but statistically nonsignificant need consideration.48
increase in cesarean sections among those
who had poor monitoring. Positive mater-
nal and perinatal outcomes were reported Evidence From Systematic
with the use of partograph from Nigeria.44 Reviews
These findings lend support for the use A systematic review by Lavender et al48
of partograph in the routine management aimed to determine the effect of using the
of labor. partograph on perinatal and maternal
morbidity and mortality, in addition to the
effect of partograph design on outcomes.
OTHER BENEFITS OF THE Randomized and quasi-randomized con-
PARTOGRAPH trolled trials involving comparisons of
Unlike other interventions in maternal partograph with no partograph, and com-
health, use of the partograph does not parisons between different partograph

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264 Mathai

designs were included. The primary ma- women in the standard care group and the
ternal outcomes were cesarean section; 970 women in the partograph group, the
oxytocin augmentation; duration of first cesarean delivery rates were 25% and
stage of labor (length of labor greater than 24%, respectively. No differences were
18 h, length of labor greater than 12 h) and reported in number of vaginal examina-
negative experience of childbirth (as de- tions, amniotomy, administration of
fined by trial authors). The primary out- oxytocin for augmentation, or significant
come for the baby was low Apgar score neonatal or maternal morbidity. For the
(less than 7 at 5 min). A total of 5 studies purposes of the systematic review, only
involving 6187 women were included in data from 1156 women in spontaneous
the review. labor-560 in the partograph group and
576 in the control group were included in
PARTOGRAPH OR NO PARTOGRAPH the analyses. The cesarean section rates in
Two studies assessed partograph versus both groups were 13%.
no partograph. There was no evidence of There are possible explanations for
any difference between partograph and false negative results that include the close
no partograph groups in cesarean section monitoring of both groups and absence of
[risk ratio (RR) 0.64, 95% CI 0.24-1.70]; mandatory interventions in either group
instrumental vaginal delivery (RR 1.00, and the Hawthorne effect. It is also pos-
95% CI 0.85-1.17) or Apgar score less sible that users may not have considered
than 7 at 5 minutes (RR 0.77, 95% the partograph central to decision
CI 0.29-2.06). making. Use of the partograph is on the
The larger of the 2 trials included in the basis of the assumption that it facilitates
systematic review was conducted in 2 sites the recognition of dystocia, thereby
in Toronto, Canada.49 A total of 1932 optimizing the timing of appropriate in-
primiparous women from 36 to 42 weeks terventions, such as amniotomy, oxytocin
gestation and cephalic presentations were augmentation or, most importantly,
randomized to 2 groups. In the standard cesarean section. Therefore, the parto-
care (control) group, labor progress was graph may be effective only when it is part
documented by standard sequential of a rigorously applied management
notes. Caregivers referred to these notes protocol as in the case of the WHO trial
when deciding on interventions for slow in South East Asia.23
progress in labor. In the partograph The second trial, from Mexico,50
group, a partograph with a 2 hours alert reported on only 3 outcomes relevant to
line, but no action line, was used in the systematic review.48 Overall the
addition to the standard sequential notes. quality of this study was low.48
Caregivers were requested to use the The results for this review were only
partograph as primary caregiver tool for pooled for the 3 specified outcomes. There
following progress in labor and for coun- were no significant differences between
seling women about progress in labor and groups in cesarean section (RR 0.64,
any proposed interventions. No manda- 95% CI 0.24-1.70, n = 1590, 2 trials);
tory action was required if progress was instrumental vaginal delivery (RR 1.00,
slow enough to cross the alert line but the 95% CI 0.85-1.17, n = 1590, 2 trials) or
authors advocated adherence to the Apgar score less than 7 at 5 minutes (RR
guidelines of the Society of Obstetricians 0.77, 95% CI 0.29-2.06). There were high
and Gynaecologists of Canada. levels of heterogeneity for the results
The trial was designed to demonstrate relating to cesarean section (I2 = 93%).
25% reduction in cesarean delivery from The smaller study on 434 women in a
17% to 12.75% or lower. Among the 962 resource-limited setting reported a reduction

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 Partograph for the Prevention of Obstructed Labor 265

in cesarean section rate with the parto- ficantly more often in the aggressive man-
graph (RR 0.38; 95% CI 0.24, 0.61). In the agement group but there was no difference
high-resource setting,49 there was no dif- in use of analgesia or Apgar scores. Com-
ference between groups (RR 1.03, 95% CI pliance by staff was poor in the aggressive
0.82 -1.28). management group. Thus whereas ag-
gressive management reduces cesarean
DESIGN OF THE PARTOGRAPH deliveries in low resource settings, it re-
Among the trials included in the compar- quires more intensive midwifery care.
ison of partograph designs, second20,21
were from the same high resource setting
(Liverpool, UK) whereas the third51 was Should the Partograph be
from a resource-limited setting (Pretoria,
South Africa). In the high resource Recommended for Prevention
setting, women in the 2-hour action line of Obstructed Labor?
group were more likely to require oxy- On the basis of results of the systematic
tocin augmentation than in the 4-hour review, Lavender and her colleagues48
action line group, (RR 1.14, 95% concluded that given the limited number
CI 1.05-1.22). When the 3-hour action of trials in this area and the heterogeneity,
and 4-hour action line were compared, it was difficult to offer any recommenda-
cesarean section rate was lowest in the tions for the routine use of the partograph
4-hour action line group and this differ- or the use of specific types of partograph.
ence was statistically significant (RR 1.70, In developed countries, the focus of man-
95% CI 1.07-2.70, n = 613, 1 trial). agement in labor concentrates on early
In the third study,51 the objective was identification and management of dysto-
to compare labor outcomes using aggres- cia to offer interventions and avoid cesar-
sive or expectant management protocols ean section.49 What do the conclusions of
in healthy nulliparous women in active the systematic review mean for develop-
labor at term, with healthy singleton preg- ing countries where the focus of managing
nancies in cephalic presentation. Women labor is on preventing maternal and peri-
were randomized to either aggressive natal death related to prolonged labor?
(n = 344) or expectant (n = 350) manage- The partograph has its origins in Africa,
ment protocols. Aggressive management a continent where access to skilled care in
entailed using a single line partograph, a childbirth has been limited. Currently
vaginal examination every 2 hours and only 46.5% of births in the African con-
use of oxytocin if the line was crossed. tinent are managed by skilled attendants,
Expectant management entailed using a but there are wide regional variations in
2-line partograph, with the alert line and a coverage rates.52 Prolonged and neglected
parallel action line 4 hours to the right, labor is common in these settings as are its
with a vaginal examination every 4 hours. consequences-high maternal mortality
If the action line was reached, oxytocin and morbidity, including obstetric fistula.
was started and women were reassessed As already discussed, data from the
every 2 hours thereafter. largest study of the partograph in
The main outcome measures were low resource settings23 which reported
mode of birth, use of oxytocin, analgesia, beneficial effects, were not available for
and neonatal outcome. Significantly further evaluation. The 2 studies50,51 from
fewer women managed aggressively had low resource settings included in the
cesarean deliveries (16%) than those man- systematic review showed a statistically
aged expectantly (23.4%) (RR 0.68; 95% significant difference in cesarean section
CI 0.5-0.93). Oxytocin was used signi- rates which merits further studies on the

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266 Mathai

role of the partograph in low resource Lack of use of the partograph was
settings. None of these studies reported identified as a prominent avoidable factor
any harmful outcomes related to use of in deaths from sepsis and hemorrhage in
the partograph. South Africa.7 One of the recommenda-
tions from the confidential reviews in
maternal deaths was that correct use of
REQUIREMENTS FOR the partograph should become a norm in
IMPLEMENTATION all institutions and that a quality assur-
The partograph requires no major capital ance program should be implemented.55
investment or expensive maintenance. The implementation strategy should also
The only resource required is a skilled include policy level interventions to
attendant. Coverage of births by skilled ensure that quality assurance activities
workers is increasing in many low are included in the key performance in-
resource settings.52 A skilled attendant is dicators of program managers.
competent to record the progress of labor,
interpret the findings and act appropri- CHALLENGES TO IMPLEMENTATION
ately when required. Appropriate actions Although the partograph is a simple and
may vary depending on the setting- inexpensive tool, it is not as widely im-
augmentation of labor, operative delivery plemented, as it should be. Studies from
or just timely referral to a higher level of Nigeria56,57 reported that only 25% to
care. Standard management protocols on 33% of caregivers surveyed were using
the actions to be taken on the basis of the partograph for routine monitoring.
partograph that are available for use at Use of the partograph was more in ter-
first and referral level1,2 and should be tiary level facilities and less at primary and
used to help in decision making. secondary levels57 where early identifica-
Training (including use of a self- tion of labor problems are perhaps more
directed learning program) improves the important.
ability of midwives to interpret parto- Caregivers may resist using the tool if
graphs.53 The use of the partograph they have insufficient knowledge and do
should be an integral part of preservice not fully understand why they have been
midwifery and obstetric training. Mid- asked to use the tool. Only one third of
wifery and obstetric teachers should care givers surveyed in Nigeria56,57 had
ensure that partographs are used routi- sufficient depth of knowledge about the
nely in all teaching facilities. A midwifery- partograph.
training module on use of the partograph Nonavailability of preprinted parto-
is available.54 graphs has also been reported as a cause
Regular supervision and monitoring of for nonutilization.56 Preprinted parto-
use of the partograph and delivery out- graphs, whereas useful are not a must.
comes are important for better implemen- Well-motivated caregivers have worked
tation. Routine reviews of all partographs well with hand-drawn cervicographs.
provide opportunities for individual and Caregivers may be asked to first record
group learning and to implement changes their detailed findings elsewhere in the
in practices. If it is not possible to review case notes and then fill in the partograph.
all partographs, at least all partographs Filling the partograph is seen as an addi-
from cases of operative deliveries, intra- tional chore for a busy health worker in
partum stillbirths, and asphyxia related such a situation and may not be motivated
neonatal deaths or morbidity, severe ma- to complete the partograph.
ternal morbidity and mortality, should be Challenges to the implementation of
reviewed. the partograph, including insufficient

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 Partograph for the Prevention of Obstructed Labor 267

knowledge, nonavailability of preprinted World Bank. Geneva: World Health Or-

partographs and workload pressure, ganization; 2008.
could be addressed with further education 5. Sreevidya S, Sathiyasekaran BW. High
on the purpose of the partograph and caesarean rates in Madras (India): a po-
local managerial support. pulation-based cross sectional study.
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6. Villar J, Valladares E, Wojdyla D, et al.
SUMMARY Caesarean delivery rates and pregnancy
The partograph is an inexpensive and outcomes: the 2005 WHO global survey
accessible tool that can effectively moni- on maternal and perinatal health in Latin
tor the progress of labor. Further research America. Lancet. 2006;367:1819–1829.
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